Inspection on 04/12/07 for Bournbrook Manor

This inspection was carried out on 4th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bournbrook Manor 20/10/08

Bournbrook Manor 03/06/08

Bournbrook Manor 12/06/07

Bournbrook Manor 28/06/06

Bournbrook Manor 24/01/06

Bournbrook Manor 07/07/05

Bournbrook Manor 23/02/05

Bournbrook Manor 19/08/04

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Maple Lodge

Heathlands

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bournbrook Manor 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD Lead Inspector Jill Brown Key Unannounced Inspection 4th December 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bournbrook Manor Address 134a Bournbrook Road Selly Park Birmingham West Midlands B29 7DD 0121 472 3581 0121 472 3581 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Rajen Odedra Usha Odedra Miss Tracey Leanne Harper Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old age not falling into any other category (19). That the manager completes the Registered Managers Award by 30 April 2007 and a copy of the certificate be sent to the Commission. 12th June 2007 Date of last inspection Brief Description of the Service: Bournbrook Manor is located in a residential area of Selly Park in South Birmingham. The home is a large detached property, which offers care to nineteen elderly people. It is well situated and gives easy access to public transport and local amenities including shops, churches and park. Accommodation is offered over two floors with 15 single and 2 double bedrooms. All but one of the bedrooms have en-suite toilet and wash hand basins, two of the bedrooms also have an en-suite shower facility. The home has a shaft lift and a stair lift (although this is rarely used) giving easy access to the first floor for those with mobility difficulties. There is an assisted shower room on the first floor and a large assisted bathroom on the ground floor, which is also equipped with a shower. There are adequate toilet facilities throughout. Communal areas comprise of two large lounges and a dining room. There is parking space on the road to the front of the home. To the rear is a well-maintained garden with a patio area and garden furniture. Access to the lawned area of the garden is problematic from the rear of the home as there are several steps to negotiate. There is alternative access to the garden by a side exit of the home. The home’s fees were not discussed at this inspection. The home has a hairdresser that calls and they charge £6.50 for a shampoo and set, £5.00 for a trim, £21.00 for a perm and £16.00 for a tint these are subject to review. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited the home on a day in December without prior notice. A key inspection was undertaken which looked at all of the key standards. The inspection took place over 9 hours. During the inspection four residents were case tracked. This case tracking involved talking to the residents looking at all the records and information about them, looking at their medication and their rooms. This assists the inspector to make a judgement about the care given. Other residents were also spoken with. Other documentation in regards to the running of this home were examined. Discussion took place with the deputy manager, manager and a representative of the organisation. Services are required to complete an Annual Quality Assurance Assessment (AQAA) on a yearly basis; information from this was used in this report. The inspector also took into account information we had received from all sources about the home since the last key inspection. The medication administration was poor at the last key inspection and three random inspections had been undertaken to look at this prior to this visit. We have received no complaints about this home. What the service does well: What has improved since the last inspection? Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 6 Residents that have been admitted recently have needs that the home can manage. All residents’ records sampled showed that their assessed needs resulted in a care plan to meet the needs identified. The carpets in three residents bedrooms have been replaced as the rooms have become vacant. The ground floor bath and shower room has been refurbished to make it more comfortable for residents to use. The majority of staff have received training in Moving and Handling, Fire Safety, Food Hygiene and Infection Control since the last inspection. What they could do better: Risk management plans could be improved to look at how risks of poor night sleep patterns and behaviour issues can be managed. Medication supply, administration, audit and recording remained poor and we are taking legal actions to secure improvements in this area. Residents’ access and satisfaction with activities varied. There was a music and physical activity session once a month and there were visits from local school children, which residents enjoyed. A number of residents that were able found that board game activities and the music did not always suit them and they were bored, other residents did not appear to have activities. The kitchen area needs to be refurbished to ensure a reasonable working temperature and that all surfaces are cleanable. Residents were not asked their views about the care they received routinely and there were not systems in place to collect information about small worries and this makes it difficult for residents to raise their concerns. Residents thought that they would talk to their relatives rather than talk to staff if they were unhappy with their care. The washing machine was not working and the response to this was inadequate to ensure good infection control and appropriate clean laundry for residents. Staffing rotas should show the roles that staff are undertaking on any shift including the manager. Where staff were off sick it should show the arrangements to cover this shift. New staff were not always given supervision and detailed induction to ensure that they undertake their new job well. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 7 The management needed to improve to ensure that practice was supported by good systems of monitoring and improvement. The systems for ensuring residents were consulted, involved and enabled were poor. Residents financial records were not always up to date and this causes difficulties in auditing. There were a number of building routine inspections that were due and no dates were found for these to be done. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 &4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information was not supplied in a way that ensured that residents can make choices about their admission. Residents’ needs were assessed and they were only admitted if the home could meet these needs. EVIDENCE: A Statement of Purpose and Service User Guide were found in reception area for relatives and residents to look at. These had not been used for some time. Service User Guides were not given to each resident on admission. The home is investigating producing a brochure that may give easy access to certain information. Although the Statement of Purpose has been reviewed the date on the outside of the document does not reflect this. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 10 Residents that are admitted to the home have an assessment undertaken. The assessment gives details of why the resident was admitted and information about their abilities and what they need help with such as the resident’s mobility, sleep pattern, ability to self care, health condition and history of falls. This assists staff to meet their needs. It was noted at this time that the service is only admitting those residents whose needs can be fully met. Residents’ religion and their ethnic origin is recorded on their care files. Residents sign to say whether they are in agreement to having a male carer there is one male care in the home at the present time. The male carer has on file information about the amount of care each resident is willing to accept from the male carer and this is good practice. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there had been some improvements in the care planning for residents there had not been enough improvement in the medication administration or risk management to ensure that health and well being of residents were maintained. EVIDENCE: Care plans were sampled and the level of information about residents’ abilities and difficulties in managing their personal care needs had improved. Residents’ care plans have information about what the resident can do for his and herself such as cleaning their dentures and this helps maintain the resident’s independence. Care plans have some personal details such as ‘wears a watch and a wedding ring’ and have helpful advice on how to communicate with residents such as ‘please give a good explanation for everything you are going to do,’ this helps the resident to assist in their care. Further development is Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 12 needed in mental health and sleep plans where the resident’s behaviour makes this necessary. In some cases the risk assessments needed reviewing, as they did not always show the level of risk prior to putting in place the risk management strategies. For example residents were being assessed as being at low risk in their mobility despite having a number of aids and staff assistance to move from place to place. A resident’s risk of pain was assessed as low because they were on medication. The care plan did not guide staff to the actions to take or the signs to look for when either medication was not given or became ineffective and the resident was experiencing increase pain. When the care plans are reviewed and new plans are written the staff are failing to transfer all the information from the initial risk assessments. In a care plan for Manual Handling the size of the sling used with the hoist for a particular resident was not recorded when the information was transferred. All Residents’ care records showed that they had gained weight since admission or if they had lost weight appropriate action had been taken and the records showed that they had regained weight. Residents observed were of a reasonable weight. We have been concerned about the way medication is administered. Since the last key inspection, when this concern was identified, there have been three visits by our pharmacist inspector and although some improvements have been made there has remained sufficient concerns for us to take legal action by issuing a statutory notice on 7th December 2007. The concerns raised in the Statutory Notice were: - tablets being recorded as given when they have not been, shortfalls in the number of tablets against the record kept and that prescribed medication was allowed to run out; this had a detrimental effect on residents. The quality assurance system devised was not sufficient to minimise the chances of these errors. During this inspection a resident spoken to said that they had experienced pain and lack of sleep due to this and said this was because of the lack of medication in the home. The resident’s records demonstrated that this was the case. Four staff have received training in medication administration since the last inspection. A further Pharmacy Inspection took place on the 31st December 2007 and found that all matter related to the administration and management of medication had improved and no further actions are to be taken. Residents spoken to thought the care they received from staff was good or all right. One resident had particular concerns during the early evening when they felt anxious. Residents were spoken to in good manner during the inspection. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities provided did not meet the needs of all residents. Residents were not restricted by the home’s routine and residents’ relatives could visit when they wished. The meals provided met the needs of residents. EVIDENCE: Residents had a varied experience of activities. Residents’ records showed that some residents had activities about twice a week throughout November. One resident’s records sampled showed no activities at all. There were records showing that pupils from the local school visited and under supervision played board games, and a mobility and exercise entertainer called once a month. Some residents enjoyed a game of bingo, sing alongs, going to the local shops and making cakes. A Christmas party has been arranged for the 20 December 2007. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 14 One resident spoken to said they felt lonely and that there were few residents that could talk to them. Another resident said they felt bored and another resident said that the entertainments were not what they liked. The homes AQAA acknowledged that the home had work to do in this area and a more organised activities programme needed arranging. Residents appeared to move around the home as they wished. The home had locked front door to protect vulnerable residents and has alarmed fire exits in response to these residents walking out when confused. Residents can spend time if their bedrooms and lock their bedroom doors if they wish. A number of residents’ bedrooms had televisions, DVD players and so on for entertainment. Residents spoken to said that relatives could visit when they wanted and relatives were attending the home during the inspection. Menus were supplied to us when we visited. These showed that residents were offered a choice of food at each meal times. Residents had the option of a cooked breakfast and a hot option at teatime as well at lunchtime. Food supplies available in the kitchen were sufficient and there are also supplies stored elsewhere in the building. Residents spoken to thought the food was satisfactory and although two residents expressed they didn’t like a particular food said that they were always offered a choice. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not in place to ensure that residents feel involved in the service, find it easy to raise concerns and are assured that this will be dealt with appropriately. EVIDENCE: We have received no complaints about this home. The manager stated that they had received no complaints. There were no records of any concerns being raised despite the manager telling us of a relative talking to them about the lack of warmth in a particular resident’s bedroom, the management had dealt with this. There was no evidence of actions taken, discussions with the relative and the overall outcome to demonstrate that this was dealt with effectively. There have been no residents’ or relatives’ meetings since the last inspection and only one survey of a relatives view was found for this year. Two residents spoken to thought that they would talk to their relative rather than to staff about any concerns they had. No adult protection issues have been raised since the last inspection. Staff have Protection of Vulnerable Adults and Criminal Records Bureau checks before starting work. Staff have been given the General Social Care Council Code of Practice and this means they are aware of their responsibilities are in Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 16 ensuring safe care to residents. A number of staff have adult protection training within their National Vocational Qualification level 2 in care. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was comfortable and homely for residents but further improvements were needed to improve the infection control in the kitchen areas and the laundry. EVIDENCE: Part of the ground floor of the building was looked at during this inspection. This tour included the kitchen, laundry, dining and lounge areas as well as a number of residents’ rooms. A number of improvements had been made to the environment. The ground floor assisted bathing facility had been refurbished to make it more homely. This included the removal of a manual sluice and installation of a hairdressing sink. Two bedrooms had been recarpetted and another bedroom was being recarpetted at the time of the inspection. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 18 The home was generally well ordered, nicely decorated and furnished. Residents had the opportunity to bring in furniture from their home; for one resident this was a double bed. The mattresses and bedding checked in sampled rooms was serviceable and clean. The home’s kitchen remained hot and in need of refurbishment. There is no dishwasher despite there being 19 residents and one cook. The kitchen surfaces are porous in places and hard to keep clean. There is lack of ventilation, which means fridges, and freezers have to be turned up high to keep food cool and the back of the fridge can freeze food. The providers have stated that they wish to ensure that a full catering kitchen is put in its place. The AQAA provided has no details of this as an area of intended improvement. A representative of the owner stated that this would hopefully be completed by the end of February 2008. The washing machine was not working during this visit. The manager stated that there had been problems with the machine the week before and it had been fully out of use for two days. There were numerous bags of washing in the laundry some that required separate cleaning and special treatment. The home was taking washing to the local laundrette, this is unacceptable and may contribute to the risk of cross infection to residents and members of the public. One resident had clean underclothes left for a day only there were no arrangements for laundering clothes on the day of the visit. An immediate requirement letter was sent informing the provider that the situation must be rectified with immediate effect. The home had also run out of blue aprons used when serving food. It was stated that these had been requested and an invoice showing that they had been was supplied to us subsequent to the inspection. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The level of staffing fluctuates and this does not demonstrate that it meets residents’ needs. The training of staff in safe methods of working with residents had improved but new staff needed a comprehensive induction to ensure they were competent in caring for residents. EVIDENCE: The home supplied us with 6 weeks staffing rotas. These showed that hours required to prepare and cook food was not recorded. The cook’s hours and the manager’s hours were included in the care numbers meaning that it is difficult to ascertain if there are sufficient hours to meet the needs of the residents and the administration of the home effectively. At the end of October beginning of November there was staff sickness and the numbers of staff were very low, there was no evidence to show that extra staff were employed during this period to maintain a safe staffing ratio. Residents spoken to had no opinion about the numbers or the availability of staff. The home has stated that 6 of the 15 current care staff (excluding the manager) have achieved a National Vocational Qualification level 2 in care. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 20 This means that 40 of care staff have achieved an understanding of the care needs of older people. The target of 50 has not been met but will be if the current staff on the course achieve this qualification. The new member of staff recruited since the last inspection had been recruited via application form and all checks had been undertaken to ensure the safety of residents. Since employment there was no evidence of supervision nor the common induction standards being completed. These are important as it ensures that new staff have the same understanding about how care is to be given. Staff have received training in Moving and handling, food hygiene, fire and infection control since the last inspection (August and September dates seen and certificates sampled) Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a lack of management and planning to ensure that the home is run in the best interests of residents and is accountable for the service provided. EVIDENCE: The manager of the home has not started the registered managers award training as she stated there have been problems with the college. She has now registered with a company to undertake this training. Visits by representatives of the provider, under Regulation 26, have not identified areas for improvement and short falls in practice in this service. They had failed to recognise the problems associated with medication Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 22 administration and management, the complaints process and the management of residents’ monies. This shows that the quality systems used are inadequate and do not ensure good planning for improvement. There was inadequate planning by the provider to manage the laundry of residents while the washing machine was out of action. The home produced an action plan stating how they were going to improve areas in the service after the last inspection. When asked for confirmation of the actions taken on the improvement plan, the manager was unable to produce this. Residents except for one have not been canvassed for their opinion about the home, there have been no residents meetings, the quality monitoring of medication, falls, accidents and so on have not been undertaken for some months. Staff have been canvassed were positive about the service; one staff member thought residents were bored. The manager stated the residents’ money was not correct with the record and therefore not auditable as money had been taken out to pay for the hairdresser and the record had not been updated. The manager stated that the money was updated on a Wednesday. Contemporary records must be kept of residents’ money. The service has the majority of the health and safety documentation to meet the requirements of a care service. However it was noted that the fixed wiring of the building, the nurse call and the emergency lighting all required an inspection. The manager stated that these had been chased with the relevant companies for completion. Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 3 X X 3 X 1 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 4 Standard OP16 Regulation 22(8) Requirement A record of complaints and concerns must be kept with details of the investigation and the outcome. A fully functioning washing machine including a sluice cycle must be available for use at all times to meet laundering needs of residents. This ensures that residents are not subjected to risks associated with cross infection. 6 OP35 17(2) Sch 4 (9) Money held for residents must be auditable at all times. Money must not be taken out of residents’ accounts without a record being made. This is to ensure that residents are protected from financial abuse. 7 OP38 23(2)(b)& (c) 23(4)(b) & The premises and equipment 15/01/08 must be maintained and inspected to ensure that they are safe. DS0000017006.V356302.R01.S.doc Version 5.2 Page 25 Timescale for action 31/12/07 5 OP26 16(2)(e); 23(2)(k) 11/12/07 31/12/07 Bournbrook Manor (c)(iv) This includes: An inspection to gain a five year fixed wiring certificate. Maintenance of the nurse call system Maintenance of the emergency lighting equipment. This is to ensure that the building and the equipment are safe at all times and the environment is safe for residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3. 4. Refer to Standard OP1 OP7 OP9 OP9 Good Practice Recommendations The statement purpose should contain information about the numbers of staff, their experience and qualifications. Care plans should contain information about how to manage behaviour and sleep disturbances where these are identified. All medicines prescribed on a when required basis should have a supporting written protocol detailing their use to ensure they are administered as the doctor intended. It is recommended that all medicines administered by the district nurse are recorded on the medicine chart with the date they are actually due to enable staff to take appropriate action if they have not been administered The purchase of current medical information text books is recommended in addition to collection of the product information leaflets supplied by the pharmacist to assist staff in knowing what the medicines they administer are for and what their general side effect are to fully support the service user in taking their medicines. Medication policies and procedures should be rewritten to reflect good practice and staff retrained to adhere to these. This is to ensure that staff can follow good procedures and are DS0000017006.V356302.R01.S.doc Version 5.2 Page 26 5. OP9 6. OP9 Bournbrook Manor 7. OP12 8. 9 10 11 OP16 OP19 OP22 OP27 assessed as able to undertake safe handling of medicines Residents that are unable to join group activities must have individual activity plan to show how they have one to one time with staff. Outstanding since 31/08/06 and 03/12/07 Complaints procedures should be in a format that makes it easy for residents to raise concerns or make comments on the service provided. A full assessment of the kitchen facilities must be undertaken and work carried out to improve facilities within a suitable time scale. The provision of signs, symbols and colour coding should be introduced to assist residents to find their way around the home. A review of the staffing levels must be undertaken and suitable action taken to ensure that these meet the needs of the residents. Staff employed must have an induction period and training to meet the Common Induction Standards. The manager must complete the Registered Managers Award. The home should improve the ways they collect residents views to improve the service and this should result in an annual report. 12 13 14 OP29 OP31 OP33 Bournbrook Manor DS0000017006.V356302.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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